Hydrofluoric Acid Exposure A Double Whammy That s Not Just Skin Deep

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1 he following report was submitted to PA-PSRS. T A patient came to the Emergency Department complaining of chest pains. He also stated he received an acid burn of the hand prior to his arrival. The ED physician assessed the hand and found it unremarkable. The next day, however, the patient s hand was noted to have 3+ edema. Two fingertips and underneath four fingernails were black. Poison Control was contacted about an hour after this assessment, resulting in immediate treatment of the hand/digits with calcium gluconate gel. The patient was transferred to a burn unit for further treatment. What happened here? Calcium gluconate gel is used to treat hydrofluoric acid (HF) burns. This report may reflect missed opportunities. The patient and the Emergency Department did not appreciate the severity of the HF exposure when the patient first presented to the ED. The ED did not contact Poison Control until the day after exposure when tissue damage was apparent, thus delaying appropriate treatment. Because of the unique characteristics of HF exposure, patients and physicians may not be aware of the damage such exposure can cause. Hydrofluoric Acid HF is an inorganic acid that is ubiquitous in many industries such as electronics/semiconductor manufacturing, oil refineries, electroplating, rock/mineral analysis. 1-3 It synthesizes fluorine-containing compounds such as Teflon 1,2 arrests fermentation in brewing, 4 and etches glass. 5 Sixty percent of HF is used to manufacture refrigerants such as Freon. 4 Several household products contain dilute HF as well, including: aerosol propellants, fire extinguishers, home rust removers, fluorescent lights, and automobile mag/wire wheel cleaners. 2,6-9 Consumers can purchase HF-containing products in stores and via the Internet, 6,10,11 but consumer product labels may not specify the injuries caused by HF exposure and the need for immediate treatment when exposure occurs. Because consumers do not recognize the danger of HF-containing products, they may not wear protective equipment as specified on the labels. 12 Patient Reprinted Safety from the PA-PSRS Patient Safety Advisory Vol. 3, No.2 (June 2006) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority Hydrofluoric Acid Exposure A Double Whammy That s Not Just Skin Deep Symptoms/Onset The severity and onset of symptoms related to HF exposure vary according to the concentration and volume of HF, the length of exposure, the exposure route, the penetrability of exposed tissue, the body surface area exposed, and the extent to which preventive/protective measures were used. 2,13,14 For example, severe burns, systemic toxicity, and life threatening electrolyte imbalances may occur with the following HF concentrations and body surface areas. 3,6,15,16 HF Concentration Body Surface Area 50% or stronger 1% or more (size of the sole of a foot) Any concentration 5% or more 60% or stronger inhalation The onset of symptoms also varies with the HF concentration: 14,17,18 HF Concentration Onset of symptoms Greater than 50% Immediately 20-50% 1-8 hours Less than 20% Delay up to 24 hours A toxidrome is a syndrome, or collection of symptoms, caused by a dangerous level of toxins in the body. 20 Table 1 presents the toxidrome for HF that indicates the need for aggressive emergency treatment. While concentrated HF causes immediate pain and produces surface burns similar to other acids, exposure to dilute HF solutions can be particularly dangerous because the onset of tissue damage may be delayed. The most common exposure is dermal, particularly the hands/digits. 3 For dilute exposures to the skin, the patient experiences severe pain that is out of proportion to the extent of tissue injury observed on initial assessment. This presentation should raise the suspicion that HF exposure has occurred. 3,21 This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 3, No. 2 June The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI & ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Copyright 2006 by the Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. To see other articles or issues of the Advisory, visit our web site at Click on Advisories in the left-hand menu bar. Page 1

2 Reprinted from the PA-PSRS Patient Safety Advisory Vol. 3, No. 2 (June 2006) Table 1 displays the variety of symptoms according to route of exposure. Table 1. Toxudrine for HF Table 1. Toxidrome for HF Exposure Exposure Ingestion 20 Oral irritation Hypotension Nausea Vomiting Abdominal pain Chest pain Inability to swallow secretions Gastrointestinal changes Voice changes Respiratory distress Pulmonary 8 Dyspnea Wheezing Hypoxia Respiratory failure Pulmonary edema Laboratory abnormalities 8 Hypocalcemia Hypomagnsemia Hyperkalemia Cardiac 5,8,19 Tachycardia Torsades de point EKG abnormalities - QRS complex widening - QT interval prolongation - Sinus tachycardia - Ventricular fibrillation Neurologic/ Neuromuscular 5,8 Lethargy Loss of deep tendon reflexes Paralysis Carpopedal spasm Trousseau s sign Seizures Obtundation Respiratory depression CNS depression Tetany Muscle weakness Facial Spasm/ Chvosteck s sign Pathophysiology HF produces tissue damage via two mechanisms (hence, the double whammy). First, free hydrogen ions cause corrosive burns. 3,13,17,18,22 Second, fluoride ions penetrate the tissue and cause chemical burns by forming insoluble salts with calcium and magnesium in the body. Fluoride ions combine with other cations to make soluble salts that dissociate quickly. As a result fluoride ions are released again, causing further tissue destruction/necrosis (hence, exposure is not just skin deep). 3,13,17,18,22 Unlike other acids which can be rapidly neutralized, the neutralization of HF may proceed for days during which tissue destruction may continue. 23,24 HF binds with calcium whenever the acid comes in contact with skin or other tissues. 23 Because calcium is required for cell life, fluoride s calcium-binding capacity may result in rapid cell death. Extensive HF exposure can inactivate large amounts of calcium in the body, significantly depleting calcium supplies required for vital bodily functions. 23 If left untreated or undertreated, minor exposure may produce the same severe consequences as high-concentration HF burns. The delayed onset of symptoms may lull patients and medical caregivers into believing that the exposure did not cause harm, prolonging exposure and delaying treatment. 25 Moreover, deterioration can be precipitous patients with minimal symptoms can progress to ventricular arrhythmia and even death within a matter of minutes after exposure to concentrated HF. 8 ROUTE OF EXPSURE Dermal TECHNIQUE Application of gel Subcutaneous infiltration IV or intra-arterial PERCENT OF CALCIUM GLUCONATE 2.5% 5% or 10% 10% Ocular Irrigation 1% Inhalation Nebulizer 2.5% Ingestion Oral and/or lavage 10% Treatment First aid and treatment for HF exposure can be quite involved and is beyond the scope of this article. Depending on the circumstances of the HF exposure, the goal is to deliver a pharmacologic antidote of calcium to the affected area: 3,26-29 The bottom line is that all HF exposures require medical evaluation and treatment regardless of whether first aid interventions were provided 15 or the size of the exposure. 1 Resources The following resources present detailed first aid, emergency responder, and medical interventions for HF exposure: Honeywell. Recommended medical treatment for hydrofluoric acid exposure [online] May [cited 2005 May 5]. Available from Internet: membership.acs.org/f/fluo/ hfmedbook.pdf. Page 2

3 Reprinted from the PA-PSRS Patient Safety Advisory Vol. 3, No.2 (June 2006) Air Products and Chemicals, Inc. Safetygram #29:treatment protocol for hydrofluoric acid burns [online] Aug [cited 2006 May 5]. Available from Internet: Responsibility/EHS/ProductSafety/ Product SafetyInformation/Safetygrams/ safetygram29.pdf. DiLuigi KJ. Hydrofluoric acid burns. AJN 2001 Jun;101(6):24AAA, 24CCC- 24DDD. Somers S. Hydrofluoric acid exposures: preparing personnel for the care of patients involved in HF acid incidents. JEMS 2002, Dec;27(12): Dunser MW, Ohlbauer M, Reider J, et al. Critical care management of major hydrofluoric acid burns: a case report, review of the literature, and recommendations for therapy. Burns 2004 Jun;30 (4): Kirkpatrick JJR, Burd DAR. An algorithmic approach to the treatment of hydrofluoric acid burns. Burns 1995;21(7): Lessons Learned While the PA-PSRS report highlighted above relates to HF exposure, implementing the following strategies will help to ensure more effective and timely interventions for any chemical exposure. Obtaining the following information when a patient presents to the ED with a chemical exposure: 3 Name of product, ingredients, concentration of chemicals Duration of exposure Any protective measures were used First aid interventions provided prior to ED presentation Medications/antidotes taken/applied If specific, written treatment protocols are not available at the treating facility, contacting Poison Control immediately so that appropriate and timely treatment is provided. Having treatment supplies 24,26 and treatment algorithms 30 readily available. Healthcare facilities, Poison Control, emergency responders, and communities can work together so that communication, education, drills, treatment supplies, and written protocols ensure coordinated and appropriate interventions to chemical exposures. Notes 1. Wikipedia. Hydrofluoric acid [online] Mar 20 [cited 2006 Mar 21]. Available from Internet: en.wikipedia.org/wiki/hydrofluoric_acid. 2. Centers for Disease Control and Prevention. Facts about hydrogen fluoride (hydrofluoric acid) (fact sheet). [online] Aug 20 [cited 2006 May 8]. Available from Internet: facts.asp. 3. Wilkes G. Hydrofluoric acid burns. Emedicine [online] Nov 19 [cited 2006 Mar 13]. Available from Internet: 4. Occupational Safety & Health Administration. Occupational safety and health guideline for hydrogen fluoride [online]. [cited 2006 Mar 28]. Available from Internet: recognition.html 5. Caravati EM. Acute Hydrofluoric acid exposure. Am J Emerg Med 1988 Mar;6(2): Sanz-Gallen P, Nogue S, Munne P, et al. Hypcalcaemia and hypomagnesaemia due to hydrofluoric acid. Occup Med (Lond) 2001 Jun;51(4): Bennion JR, Franzblau A. Chemical pneumonitis following household exposure to hydrofluoric acid. Am J Ind Med 1997 Apr;31(4): Perry HE. Pediatric poisonings from household products: hydrofluoric acid and methacrylic acid. Curr Opin Pediatr 2001 Apr;13(2): Mangeon SM, Beulke SH, Braitberg G. Hydrofluoric acid burn from a household rust remover. Med J Aust 2001 Sep 3;175(5): Fujimoto K, Yasuhara N, Kawarada H, et al. Burns caused by hydrofluoric acid in the bleach. J Nippon Med Sch 2002 Apr;69(2): Ohata U, Hara H, Suzuki H. 7 cases of hydrofluoric acid burn in which calcium gluconate was effective for relief of severe pain. Contact Dermatitis 2005 Mar;52(3): Siegel DC, Heard JM. Intra-arterial calcium infusion for hydrofluoric acid burns. Aviat Space Environ Med 1992 Mar;63(3): Sadove R, Hainsworth D, VanMeter W. Total body immersion in hydrofluoric acid. South Med J 1990 Jun;83 (6): Lin TM, Tsai CC, Lin SD, et al. Continuous intra-arterial infusion therapy in hydrofluoric acid burns. J Occup Environ Med 2000 Sep;42(9): Northwestern University. ORS Emergency Response. Calcium gluconate gel as an antidote to hydrofluoric acid burns on skin [online] [cited 2006 Mar 13]. Available from Internet: research/ors/emerg/firstaid/calglugel.htm 16. Ohtani M, Nishida N, Chiba T. Pathological demonstration of rapid involvement into the subcutaneous tissue in a case of fatal hydrofluoric acid burns. Forensic Sci Int 2006 Jan 19 [online]. [E pub ahead of print]. [cited 2006 May 8]. Available from Internet search by Pathological Demonstration and select article from the list: Huisman LC, Teijink JA, Overbosch EH, et al. An atypical chemical burn. Lancet 2001 Nov 3358(9292):1510. Page 3

4 Reprinted from the PA-PSRS Patient Safety Advisory Vol. 3, No. 2 (June 2006) 18. el Saadi MS, Hall AH, Hall PK, et al. Hydrofluoric acid dermal exposure. Vet Hum Toxicol 1989 Jun;31(3): Holstege C, Baer A, Brady WJ. The electrocardiographic toxidrome: the EKG presentation of hydrofluoric acid ingestion. Am J Emerg Med 2005 Mar;23(2): Wikipedia. Toxidrome [online] Mar 11 [cited 2006 Mar 31]. Available from Internet: Toxidrome. 21. Bartlett D. Tricky toxic presentations at triage. J Emerg Nurs 2005 Aug;31(4): Rutan R, Rutan T, Deitch E. Electricity and the treatment of hydrofluoric acid burns the wave of the future or a jolt from the past? Critical Care Medicine 2001 Aug;29(8): Northwestern University. ORS Emergency Response. First aid procedure for responding to hydrofluoric acid burns [online] [cited 2006 Mar 13]. Available from Internet: emerg/firstaid/hfburns.htm 24. Piraccini BM, Rech G, Pazzaglia M, et al. Peri- and subungual burns caused by hydrofluoric acid. Contact Dermatitis 2005 Apr;52(4): Laubacher M. Don t get burned treating hydrofluoric acid. Emerg Med Serv 2000 Nov;29(11): Air Products and Chemicals, Inc. Safetygram #29: treatment protocol for hydrofluoric acid burns [online] Aug [cited 2006 May 5]. Available from Internet: Responsibility/EHS/ProductSafety/ProductSafetyInformation/ Safetygrams/safetygram29.pdf. 27. Honeywell. Recommended medical treatment for hydrofluoric acid exposure [online] May [cited 2006 May 5]. Available from Internet:membership.acs.org/F/FLUO/hfmedbook.pdf 28. Air Products and chemicals, Inc. Hydrofluoric acid burns: health effects and treatment plan for medical professionals and emergency responders [online] Jun [cited 2006 May 8]. Available from Internet: C C6FA-48D7-BB55-01EB758A3Ac1/0/ HFBurns02.doc. 29. Bartlett D. Dermal exposure to hydrofluoric acid causing systemic toxicity. J Emerg Nurs 2004 Aug;30(4): Burd A. The management of hydrofluoric acid burns. J Occup Environ Med 2002 Apr;44(4):309. Page 4

5 Reprinted from the PA-PSRS Patient Safety Advisory Vol. 3, No.2 (June 2006) An Independent Agency of the Commonwealth of Pennsylvania The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error ( Mcare ) Act. Consistent with Act 13, ECRI, as contractor for the PA-PSRS program, is issuing this newsletter to advise medical facilities of immediate changes that can be instituted to reduce serious events and incidents. For more information about the PA- PSRS program or the Patient Safety Authority, see the Authority s website at ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organizations worldwide. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP's efforts are built on a non-punitive approach and systems-based solutions. Page 5